Step Therapy Programs for Members on the Balanced Biosimilar Drug List
Customize your policy alerts
Sign up for all alacura_medical_transportation_management policy alerts
Know when alacura_medical_transportation_management releases new policies or updates existing guidance.
Monitor payer policy activity
Defines drugs and categories subject to step therapy requirements under the payer's Balanced Biosimilar Drug List for members; affects prescribing providers and members covered by the payer's prescription drug benefit.
No material clinical or coverage changes in this revision.
Coverage Criteria Summary
This policy does not list specific exclusions. It notes that the drug lists and step therapy programs are examples and may change over time. If a medication is not included on the payer's Drug List, the member or the prescribing health care provider may request an exception review to consider coverage for that drug.
As part of any exception review, the member may be required to meet the drug's step therapy program criteria before the request can be approved. For assistance or to initiate an exception review, callers should use the telephone number printed on the member's ID card.
What Providers and Members Must Do
Step therapy requirement and exception review
Some medications listed require completion of a step therapy program before coverage; an exception review process is available if the drug is not on the Drug List or the member believes criteria should be waived.
- An exception review may still require meeting the drug's step therapy program criteria before approval.
- To start the review process, call the number on the Member ID card or have the prescriber visit the provider site listed.
Drug categories subject to step therapy
The document lists multiple drug categories and example medications that may be subject to step therapy programs; these categories include atypical antipsychotics, depression (antidepressants), insomnia agents, gabapentin ER, topical NSAIDs, and others with many example brand names provided.
- Atypical antipsychotics (examples: Abilify, Clozaril, Saphris, Fanapt, Geodon, Invega, Latuda, Zyprexa, etc.)
- Depression/antidepressants (examples: Auvelity, Bupropion ER 450 mg, Lexapro, Paxil, Celexa, Cymbalta, Effexor, Prozac, Sertraline, etc.)
- Insomnia agents (examples: Ambien, Ambien CR, Lunesta, Quviviq, Belsomra, Rozerem, Dayvigo, Silenor, Zolpidem, etc.)
- Gabapentin ER (Gralise, Horizant) and Topical NSAIDs (Kerendia listed)
Contact instructions for exception review
Prescribers or members must call the phone number listed on the member's ID card to initiate questions or start an exception review; the prescriber may be asked to provide supporting documentation and providers can also be directed to the payer's provider site.
- Call the number on the Member ID card to start an exception review.
- Prescribers may be asked to provide documentation that step therapy criteria are met or to visit bcbsmt.com/provider to start the review.
Denial risk if step therapy criteria not met
Requests for coverage or exception reviews may be denied if the member or prescriber does not meet the step therapy program criteria during the review.
- An exception review does not guarantee approval — the drug's step therapy criteria must be met before approval may be granted.
Policy Background
This document is administrative and provides examples of drug categories and specific medications that may be included in the payer's step therapy programs under the Balanced Biosimilar Drug List. It does not provide clinical rationale, detailed clinical criteria, or individual step definitions.
The listed categories and medications are illustrative and the programs are subject to change. For questions or to begin an exception review, members and prescribers should call the number on the member ID card or have the prescriber visit the referenced provider website.
Key Definitions
Initial Therapy / Step Requirements
Initial Therapy Criteria
Covered when ALL of the following are met:
ALL of the following
- The requested medication is included in a drug category for which the payer may apply a step therapy program (examples include insomnia agents, atypical antipsychotics, antidepressants, topical NSAIDs, and others listed by the payer).
- The member or prescriber has not already completed the required preferred step(s) specified by the payer for that drug category; when applicable, step therapy requires trying specified preferred agents before coverage for other agents is provided.
- If the drug is not on the payer's Drug List or the member does not meet the step therapy requirements, an exception review may be requested by the member or prescribing provider.
- To initiate an exception review or for questions about step requirements, the member or prescriber must call the phone number on the Member ID card or follow the provider instructions on the payer website.
Step Therapy Program Details
| Drug category / examples | Step therapy applies? | Notes / exception review |
|---|---|---|
| Atypical Antipsychotics — examples: Abilify, Risperidone ODT, Clozaril, Saphris, Fanapt, Geodon, Seroquel, Invega, Latuda, Zyprexa | covered | These drug categories and example medications may be subject to step therapy programs; members/providers may request an exception review if a drug is not on the Drug List |
| Depression (antidepressants) — examples: Auvelity, Bupropion ER 450 mg, Lexapro, Paxil, Celexa, Citalopram, Cymbalta, Desvenlafaxine ER, Effexor, Fluoxetine, Wellbutrin SR, Sertraline | covered | Step therapy may require trying preferred agents first; exception review is available by calling the number on the Member ID card or having the prescriber request review |
| Insomnia agents — examples: Ambien (zolpidem), Lunesta, Quviviq, Belsomra, Rozerem, Dayvigo, Silenor, Edluar | covered | Insomnia medications listed as examples may be included in step therapy programs; exception review process applies as described in the policy |
| Gabapentin ER — examples: Gralise, Horizant | covered | Listed as examples of agents that may be subject to step therapy |
| Topical NSAIDs / Other — example: Kerendia listed; topical NSAIDs noted | covered | Additional drug categories and medications may be added; if a drug is not on the Drug List, an exception review can be requested and may require meeting step therapy criteria |
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.